Amity Medical Group, Inc.

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

AMITY MEDICAL GROUP, INC.

Practice address

6010 E W T Harris Blvd
Charlotte, NC 28215-4084

Phone

(704) 208-4134

Fax

(704) 248-8068

NPI assigned

Jun 28, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dequeena Smith

Title

Credentialing

Phone

(704) 493-5326

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in NC7 enrollments

Enrollment records 7

Federally qualified health center certification: CCN B61017

Legal name

AMITY MEDICAL GROUP INC

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Oct 27, 2023

Last certification

Oct 27, 2023

Ownership / control type

For profit – corporation

Organization structure

OtherNon-profit

Enrollment address

6010 E W T Harris Blvd
Charlotte, NC 28215-4084

Federally qualified health center certification: CCN B61025

Legal name

AMITY MEDICAL GROUP INC

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Mar 7, 2024

Last certification

Mar 7, 2024

Ownership / control type

For profit – corporation

Organization structure

OtherNon-profit

Enrollment address

9835 Monroe Rd
Ste B
Charlotte, NC 28270-1471

Federally qualified health center certification: CCN B61026

Legal name

AMITY MEDICAL GROUP INC

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Jan 2, 2024

Last certification

Jan 2, 2024

Ownership / control type

For profit – corporation

Organization structure

OtherNon-profit

Enrollment address

824 Lower Dallas Hwy
Dallas, NC 28034-9368

Federally qualified health center certification: CCN B61049

Legal name

AMITY MEDICAL GROUP INC

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

May 7, 2024

Last certification

May 7, 2024

Ownership / control type

For profit – corporation

Organization structure

OtherNon-profit

Enrollment address

7945 N Tryon St
Ste 112
Charlotte, NC 28262-3587

Federally qualified health center certification: CCN B61046

Legal name

AMITY MEDICAL GROUP INC

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Mar 29, 2024

Last certification

Mar 29, 2024

Ownership / control type

For profit – corporation

Organization structure

OtherNon-profit

Enrollment address

2300 Randolph Rd
Ste a
Charlotte, NC 28207-1586

Federally qualified health center certification: CCN B61047

Legal name

AMITY MEDICAL GROUP INC

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Apr 1, 2024

Last certification

Apr 1, 2024

Ownership / control type

For profit – corporation

Organization structure

OtherNon-profit

Enrollment address

4651 Charlotte Park Dr
Ste 100
Charlotte, NC 28217-3037

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Networks

• SC HMO

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Practitioners 29

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Clarence O'Neil Ellis, MD

  • Internal Medicine Physician
  • Charlotte, NC
  • NPI 1376505305
  Medicare reassignment Care Compare group NPD
• Heather Michelle Manos, M.D.

  • Addiction Medicine (Family Medicine) Physician
  • Charlotte, NC
  • NPI 1427186022
  Medicare reassignment Care Compare group NPD
• Karlton Shea Pettis, MD

  • Internal Medicine Physician
  • Charlotte, NC
  • NPI 1871555375
  Medicare reassignment Care Compare group NPD
• Richard Thomas Wynn, M.D.

  • Family Medicine Physician
  • Charlotte, NC
  • NPI 1356365480
  Medicare reassignment Care Compare group NPD
• Chad Ellis

  • Medical Physician Assistant
  • Charlotte, NC
  • NPI 1154889996
  Medicare reassignment Care Compare group
• Hana Kim, PA-C

  • Medical Physician Assistant
  • Mount Olive, NC
  • NPI 1760719348
  Medicare reassignment Care Compare group
• Clayton Gray Williams, DMS, PA-C

  • Physician Assistant
  • Charlotte, NC
  • NPI 1346971280
  Medicare reassignment Care Compare group
• Sheldine Edwards, NP

  • Family Nurse Practitioner
  • Charlotte, NC
  • NPI 1952603441
  Medicare reassignment NPD
• Jason Lamarr Hardin, MSN, APRN, AGNP-C

  • Family Nurse Practitioner
  • Charlotte, NC
  • NPI 1932675758

  Family Medicine

  Medicare reassignment NPD
• Sarah Tench Helms, FNP-C

  • Family Nurse Practitioner
  • Dallas, NC
  • NPI 1083964290
  Medicare reassignment NPD
• John Patrick Mohan, LCMHCA, LCAS-A

  • Addiction (Substance Use Disorder) Counselor
  • Charlotte, NC
  • NPI 1316749922
  Medicare reassignment NPD
• Ashley Nicole Prince, DNP

  • Nurse Practitioner
  • Dallas, NC
  • NPI 1740938646
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1530144000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722384000000",
    "number": "1003301300",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6010 E W T HARRIS BLVD",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282154084",
            "telephone_number": "704-208-4134",
            "fax_number": "704-248-8068"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6010 E W T HARRIS BLVD",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282154084",
            "telephone_number": "704-208-4134",
            "fax_number": "704-248-8068"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10508 Park Rd Ste 130",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282108526",
            "country_code": "US",
            "telephone_number": "704-208-4134",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "9835 Monroe Rd # B",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282701471",
            "country_code": "US",
            "telephone_number": "704-208-4134",
            "fax_number": "704-246-8068",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "824 Lower Dallas Hwy",
            "address_purpose": "LOCATION",
            "city": "Dallas",
            "state": "NC",
            "postal_code": "280349368",
            "country_code": "US",
            "telephone_number": "704-208-4134",
            "fax_number": "704-246-8068",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "7945 N Tryon St Ste 112",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282623587",
            "country_code": "US",
            "telephone_number": "704-764-1387",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2300 Randolph Rd Ste A",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282071586",
            "country_code": "US",
            "telephone_number": "704-764-1387",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "AMITY MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-06-28",
        "last_updated": "2024-07-31",
        "certification_date": "2024-07-31",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "DEQUEENA",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "704-493-5326"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Chandni Amin, FNP-C
• Ketan Bipinchandra Amin, MD
• Niral Amin, PSYD
• Michael M Amiri, MD
• Deborah Naomi Amirtham, M.D.
• Amity Obstetrics and Gynecology Assoc, P.a.
• Lauren Kelley Ammar, P.A.-C
• Amanda Amodeo, DPT
• Amongst Friends Inc.
• Amor Homecare Inc of NC

• Federally Qualified Health Center (FQHC) in Charlotte, NC
• Providers in Charlotte, NC by specialty
• Federally Qualified Health Center (FQHC) in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.